The Second Annual Medical Research Summit BILLING AND

  • Slides: 22
Download presentation
The Second Annual Medical Research Summit BILLING AND RESEARCH: A Practical Approach Toward Compliance

The Second Annual Medical Research Summit BILLING AND RESEARCH: A Practical Approach Toward Compliance by Sandy Piersol & Kim St. Amant © Deloitte & Touche LLP

Session Objectives Learn more about… • Techniques to untangle the web of regulatory compliance

Session Objectives Learn more about… • Techniques to untangle the web of regulatory compliance issues around clinical research • Practical ways to apply what you have learned at this Summit to mitigate risk and add value to your research enterprise • Research billing compliance (case study illustrations) 2 © Deloitte & Touche LLP

Untangling the web of regulatory compliance issues • All of the OIGs compliance guidance

Untangling the web of regulatory compliance issues • All of the OIGs compliance guidance documents are organized around risk areas – areas of vulnerability • Identifying and understanding where the enterprise is vulnerable is the best starting point for figuring out what steps are needed to prevent problems • This risk assessment process is precisely how generic compliance program principles can be fashioned into practical applications 3 © Deloitte & Touche LLP

Risk Assessment Framework FORMULA: Risk Areas Controls _________ = Assessment of Risk 4 ©

Risk Assessment Framework FORMULA: Risk Areas Controls _________ = Assessment of Risk 4 © Deloitte & Touche LLP

Risk Assessment Approach Step 1: Step 2: Step 3: Step 4: Step 5: Identify

Risk Assessment Approach Step 1: Step 2: Step 3: Step 4: Step 5: Identify risk areas Prioritize high risk areas Assess risk Analyze findings and solutions Operationalize corrective actions Repeat As Necessary 5 © Deloitte & Touche LLP

Risk Assessment Approach Step 1: Identify Risk Areas • What risk areas have special

Risk Assessment Approach Step 1: Identify Risk Areas • What risk areas have special relevance to your research portfolio? • Where is the research enterprise vulnerable? • Risks areas are not static – New laws and regulations (or interpretations) – New lines of business – New ways of doing things – New staff 6 © Deloitte & Touche LLP

Risk Assessment Approach Step 1: Identify Risk Areas • Sources for Identifying Risk Areas

Risk Assessment Approach Step 1: Identify Risk Areas • Sources for Identifying Risk Areas – OIG documents: compliance program guidance, special fraud alerts, advisory opinions, audit reports, inspection reports, annual work plans and semiannual reports – Analysis of applicable laws, regulations and interpretations – Relevant lawsuits, qui tam cases, settlement agreements – Stated enforcement priorities – Conferences, industry newsletters, word of mouth 7 © Deloitte & Touche LLP

Compliance Risk in Clinical Research Human Subject Reimbursem ent of Costs Protection Billing Kickbacks

Compliance Risk in Clinical Research Human Subject Reimbursem ent of Costs Protection Billing Kickbacks Compliance 8 © Deloitte & Touche LLP

Risk Assessment Approach Step 2: Prioritize High Risk Areas • Unless resources are unlimited,

Risk Assessment Approach Step 2: Prioritize High Risk Areas • Unless resources are unlimited, it is essential to start with the risk areas that are most likely to give rise to “liability” $$$ – Strategy: Emphasize attention upon higher risk areas and devote less effort to lower risk areas 9 © Deloitte & Touche LLP

Risk Assessment Approach Step 3: Assess Risk • Determine “current state” of compliance –

Risk Assessment Approach Step 3: Assess Risk • Determine “current state” of compliance – Are we in compliance? Yes-No-Maybe • If Yes, why? …. . Got Lucky or Was it by Design • If No, why not? …. Redesign Control 10 © Deloitte & Touche LLP

Risk Assessment Approach Step 4: Analyze Findings and Solutions • Seek to understand the

Risk Assessment Approach Step 4: Analyze Findings and Solutions • Seek to understand the cause and extent of the problems identified – Evaluate the need for further investigation – Not every “rumor” requires investigation • Identify plausible solutions and timeframe for corrective action 11 © Deloitte & Touche LLP

Risk Assessment Approach Step 5: Operationalize Corrective Actions • Prioritize corrective actions and assign

Risk Assessment Approach Step 5: Operationalize Corrective Actions • Prioritize corrective actions and assign accountability • Operationalize corrective actions through • Policies and procedures • Training • Monitoring and Auditing – Strategy: Compliance controls should be part of the basic infrastructure (controls should be “built-in” versus “added-on”) 12 © Deloitte & Touche LLP

Research Billing Compliance Case Study Illustration Note: case study materials are not included in

Research Billing Compliance Case Study Illustration Note: case study materials are not included in conference binder 12 © Deloitte & Touche LLP

Research Billing Compliance Defined Research Billing Compliance • Billing patients or third party payors

Research Billing Compliance Defined Research Billing Compliance • Billing patients or third party payors for products and services provided to patients enrolled in clinical trials in accordance with applicable laws and regulations including: – Federal health care program requirements e. g. , Medicare Part A, B &C • National and Local Coverage Policies • Final National Coverage Determination (NCD), Medicare Coverage Policy – Clinical Trials (Sept. 19, 2000) – Coding guidelines established by the cooperating parties for the International Classification of Diseases, 9 th revision, 6 th edition, Clinical Modification (“ICD-9 -CM”): AHA, AHIMA, CMS and the National Center for Health Statistics – Procedural coding guidelines developed and maintained by the AMA and published in CPT Assistant.

Research Billing Compliance Step 1: Identify Risk Areas Risk areas relating to the costs

Research Billing Compliance Step 1: Identify Risk Areas Risk areas relating to the costs of clinical research and experimental drug trials specific to hospitals: • Billing Medicare (or the patient) for items or services that are otherwise reimbursable (or free) to the hospital through federal or private grant funds – a. k. a. “double billing” • Billing Medicare for experimental drugs, devices or procedures • Charging for an investigation drug in a clinical trial under an investigational new drug application without approval of the FDA • Waiving Medicare copayments and deductible obligations for study participants • Receiving remuneration from research sponsors that could be viewed by Medicare as kickbacks • Coding and billing for noncovered items or services as a covered benefit by an insurer • Billing for items and services solely to satisfy data collection needs • Billing for items and services provided solely to determine trial eligibility • Inadequate medical record documentation for items or services billed • Upcoding of billable services • Use of Advance Beneficiary Notices (ABNs) • Other typical compliance risks applicable to federal health care programs e. g. , credit balances, MSP, etc. 12 © Deloitte & Touche LLP

Research Billing Compliance Step 2: Prioritize High Risk Areas • Identify studies with billing

Research Billing Compliance Step 2: Prioritize High Risk Areas • Identify studies with billing compliance risk – Federally funded studies – Medicare beneficiary enrollment – Protocols with billable items or services • Cost/payment provisions per informed consent form • Funding provisions per study agreement • Next, determine which risk areas have special relevance and attempt to rank them low to high 12 © Deloitte & Touche LLP

Research Billing Compliance Step 3: Assess Risk • “Current State” Assessment Techniques – Interview

Research Billing Compliance Step 3: Assess Risk • “Current State” Assessment Techniques – Interview key personnel (e. g. , PI, Coordinators, HIM, Patient Accounting, Reimbursement Specialist, Budget/Finance) – Check for complaints/correspondence – Review policies and procedures – Test medical records and billing information – Data mining – Look for data trends or patterns 12 © Deloitte & Touche LLP

Research Billing Compliance Step 4: Analyze Findings and Solutions • What caused the problem?

Research Billing Compliance Step 4: Analyze Findings and Solutions • What caused the problem? – Breakdown in internal controls – Lack of policies and procedures – Lack of training and education • How can the problem be fixed? – – – Implement system controls Revise/implement policies and procedures Clarify personnel responsibilities Improve communication and reporting Provide training and education Internal auditing 12 © Deloitte & Touche LLP

Research Billing Compliance Step 5: Operationalize Corrective Actions • Build in compliance controls (front

Research Billing Compliance Step 5: Operationalize Corrective Actions • Build in compliance controls (front to back) – Budgeting process controls – Formalize billing protocol development policies and procedures – Design monitoring controls – Ongoing training and communication to increase awareness – Close-out audits 12 © Deloitte & Touche LLP

Adding Value Through Compliance • Optimizing the research revenue stream – How much does

Adding Value Through Compliance • Optimizing the research revenue stream – How much does the research enterprise contribute to the organization? • How much research is the organization funding? • Which areas are Winners? Losers? – Are you capturing appropriate reimbursement for all “billable” services? Are you leaving any dollars on the table? • Do you have billing protocol controls in place? Is the billing protocol comprehensive?

Summary • Whether your compliance program is new or well established, it is important

Summary • Whether your compliance program is new or well established, it is important to periodically evaluate if ethical and regulatory standards are adequately addressed • Risk assessment is not a one-time event, ongoing identification and monitoring of risk areas is mission critical • Don’t underestimate the importance of increasing awareness of risk areas • Best practices may not exist, the right solutions depends on several factors • The recent expansion of Medicare coverage of clinical trials does not eliminate the risk of inappropriate billing • Revitalize the research revenue stream through compliance 12 © Deloitte & Touche LLP

Questions & Answers Sandy Piersol, Senior Manager Deloitte & Touche LLP National Healthcare Regulatory

Questions & Answers Sandy Piersol, Senior Manager Deloitte & Touche LLP National Healthcare Regulatory Services Practice, Clinical Research Consulting Team Kim St. Amant, Senior Manager Deloitte & Touche LLP National Healthcare Regulatory Services Practice, Clinical Research Consulting Team (215) 405 -7812 [email protected] com (617) 437 -3467 [email protected] com 12 © Deloitte & Touche LLP